Determining the most effective level of care needed is essential to a well-run and efficient behavioral health care system and to reducing the overall levels of violence throughout the world.
Violent behavior is a separate issue, which can co-occur with mental illness. Both must be assessed with tools that are appropriate. That assessment should result in a treatment plan that improves mental functioning and coping skills and reduces the risk for violent acting out and mental deterioration.
To have a treatment plan that only addresses mental health issues when there is also risk for violence is insufficient. Types of interventions and dosage issues should both be addressed by the assessment. Re-assessment should indicate that the risk of future violence is being reduced.
For example, in addressing levels of care, those with a mild Axis I diagnosis of mood disturbance, ADHD, or anxiety, who have no history of violence or psychosis, may find that reading selfhelp books give them the information they need to essentially self-treat their condition without medication and create more satisfying lives.
Those with moderate depression etc. probably will require and improve with traditional individual talk therapy techniques such as CBT once a week for six months or less.
Persons suffering from two diagnosable conditions such as mood or anxiety disorders and substance abuse issues will likely require specialized group, individual and sometimes family therapy twice a week for as long as two years. Recovery rates for those with dual diagnoses are typically 50 percent. Those with severe Axis I diagnoses, such as mood and anxiety disorders or schizophrenia, and Axis II or personality disorders and histories of trauma, and who have been or are at risk for becoming criminal or violent need complex interventions involving multiple agencies, multiple times per week, including family involvement in therapy, case management, specialized services, skill building and trauma work.
Recovery rates for this group are typically only 30 percent. Most end up incarcerated, in rehab, hospitalized or dead. Intensive community services are far less expensive and more effective than hospitalization or incarceration and a good deal for taxpayers.
Individual weekly therapy for the mild to moderate group has a recovery rate of around 90 percent. If one uses individual, short-term talk therapy for those with more severe conditions and more complex histories, they are applying the incorrect techniques and dosage for the clinical needs of the client.
The therapy is likely to be less effective and the recovery rate is often much lower than when the treatment is matched with client needs.
This is very elementary to most therapists who increase or decrease services depending on client need. Given recent shootings by those who were clearly mentally ill or autistic, there is pressure for better treatment for the mentally ill to prevent them becoming violent.
There have been some major misconceptions by the public and media regarding the link between mental illness and violent behavior. While mental illness is a piece of the puzzle, it only results in violent outcomes when it is accompanied by the collision of many seemingly insurmountable problems and weak coping skills and supports.
When we help these people change the balance in their lives to one with more coping skills and fewer issues, they can begin to see a more positive path for themselves. This means that these people need very practical help with safe homes, secure jobs and job skills, good health, adequate income, a reason for living, natural supports and community involvement (SAMHSA Life Domains).
For those at moderate and high risk for violence, this is not traditional therapy as most therapists see it. It is more similar to what departments of social services and vocational rehabilitation might provide.
To help those that are at high risk for violence they need to learn coping skills that we all take for granted, such as patience, delaying gratification, speaking in a calm tone or soothing oneself when angry, seeing things from another person’s point of view and learning how to make a budget and open a checking account.
These people need evaluations for the level of developmental skills that they have achieved and what skills may be lacking or missing due to trauma or family chaos. They are usually not ready for insight-oriented talk therapy and need multiple services per week often from multiple agencies.
For the clients at high risk for violence there needs to be interagency treatment teams that work together on developmental skill assessment and skill teaching, family and trauma therapy, housing, job skills and the basic necessities of life. If we were able to apply the most helpful level of services to all clients, the system would be more efficient and cost effective. Outcomes would be better and the cost to society would be less as well.
Clinicians would be able to help young people before a situation got out of control, meaning early detection and interventions for those at risk for violence.
Studies deriving out of the CDC Aversive Childhood Experiences study are showing that aversive life experiences in childhood are associated with poorer social and physical outcomes for adults, including depression, substance abuse, tobacco use and heart disease.
Additionally, the research of Moffit, et al, in 2003, indicates that the source of life course anti-social behaviors is neurodevelopmental, worsening over time and life-long.